The hospital management practices in Chinese county hospitals and its association with quality of care, efficiency and finance.

BACKGROUND: County hospitals as the backbone of the China's healthcare system are providing services for over 70% of the total population. However, the hospital management practice (HMP) and its links with quality of care, efficiency and finance in these hospitals are unknown. METHODS: We did two cross-sectional surveys of HMP in 2013 and 2015 among 101 county hospitals across rural China. Three managing roles (hospital director, director of medical affairs office and director of cardiology) and a cardiologist were invited to the surveys. A novel HMP rating scale, with 100 as full score, was used to measure the HMP in 17 indicators under four dimensions (target, operation, performance, and talent management) for each hospital. We analyzed the association of HMP score with variables on quality of care, efficiency and finance using linear mixed models with and without adjustment for potential confounders. FINDINGS: A total of 95 hospitals participated in at least one survey and were included in the analysis. The overall mean HMP score varied dramatically across the hospitals and 84% of them scored less than 60. The dimension mean HMP score was 38.6 (target), 56.4 (operation), 53.2 (performance) and 55.7 (talent), respectively. The pattern of indicator mean HMP score, however, was almost identical between hospitals with high and low overall HMP score, showing the same 'strength' (staff satisfaction, staff performance appraisal, 'hard wares', patient-centered services, etc.) and 'weakness' (target balance, target setting, continuous quality improvement, penalties on staff with dissatisfied performance, etc.). The associations of overall mean HMP score with quality of care and efficiency variables and cost per hospitalization was not statistically significant. The statistical significance in the association with hospital annual total income disappeared after adjusting for region, teaching status, number of competitors, number of staff and number of beds in use. CONCLUSION: The HMP in Chinese county hospitals scores low in general and was not significantly associated with hospital care quality, efficiency and finance. The current healthcare reform in China should address the micro level issues in hospital management practices.

Outcomes of the national programme on prevention of mother-to-child transmission of hepatitis B virus in China, 2016-2017.

BACKGROUND: In addition to providing free hepatitis B vaccine (HBvacc) series to all infants in China since 2005, the national programme on prevention of mother-to-child transmission (PMTCT) of hepatitis B virus (HBV) started providing free hepatitis B immunoglobulin for all new-borns born to hepatitis B surface-antigen (HBsAg) positive mothers in 2010. However, few studies have evaluated the effectiveness of the PMTCT programme. Therefore, we aimed to investigate the outcomes of the programme and identify associated factors. METHOD: Using a cross-sectional study design, we collected data on 4112 pairs of HBsAg-positive mothers and their children aged 7-22 months in four representative provinces through interviews and medical record review. We tested HBsAg and hepatitis B surface antibody (anti-HBs) of children by enzyme-linked immunosorbent assay at designated maternal and child hospital laboratories. We used logistic regression to analyse factors associated with child HBsAg and anti-HBs positivity. RESULTS: Thirty-five children were HBsAg positive, indicating the mother-to-child transmission (MTCT) rate was 0.9% (0.6-1.1%). The anti-HBs positive rate was 96.8% (96.3-97.4%). Children receiving HBvacc between 12 and 24 h of birth were 2.9 times more likely to be infected than those vaccinated in less than 12 h (adjusted odds ratio [aOR] = 2.9, 95% confidence interval [CI]: 1.4-6.3, P = 0.01). Maternal hepatitis B e-antigen (HBeAg) positivity was associated with higher MTCT rate (aOR = 79.1, 95% CI: 10.8-580.2, P <  0.001) and lower anti-HBs positive rate (aOR = 0.4, 95% CI: 0.3-0.6, P <  0.001). Children with low birth weight (LBW) were 60% less likely to be anti-HBs positive than those with normal birth weight (aOR = 0.4, 95% CI: 0.2-0.8, P = 0.01). CONCLUSIONS: The MTCT rate was lower than the 2030 WHO elimination goal, which implies the programme is on track to achieve this target. As earlier HBvacc birth dose (HBvcc-BD) was associated with lower MTCT rate, we suggest that the PMTCT programme work with the Expanded Programme on Immunization (EPI) to modify the current recommendation for early HBvcc-BD to a requirement. Our finding that LBW was associated with lower anti-HBs positivity points to the need for further studies to understand factors associated with these risks and opportunities for program strengthening. The programme needs to ensure providing essential test to identify HBeAg-positive mothers and their infants and provide them with appropriate medical care and follow-up.

Acceptability and feasibility of dual HIV and syphilis point-of-care testing for early detection of infection among pregnant women in China: a prospective study.

OBJECTIVE: To assess the feasibility and acceptability of using WHO prequalified combined dual HIV/syphilis rapid diagnostic tests (RDT) for same-day results in antenatal care (ANC) clinics. METHODS: This is a pragmatic implementation study using quantitative approach to evaluate outcomes. Antenatal clinic attendees from 21 rural and urban township hospitals in two provinces of China were offered with free dual RDTs testing that included HIV and syphilis, in addition to the routine blood tests. Study outcomes included testing uptake before and during dual RDT use, test feasibility and acceptability among pregnant women. Regression model was used to assess acceptance of RDT testing. RESULTS: In total, 1787 out of 1828 pregnant women attending ANC received the RDT testing. Testing uptake among pregnant women in their first and second trimester increased from 76.0% (2438/3269) using standard blood testing to 90.1% (1626/1787) with concurrent RDT use (χ2=197.1, p<0.001). Among 1787 pregnant women who received RDT tests, 98.3% (1757/1787) participants were given test result the same day. Positive proportions of HIV and syphilis screened with RDT were 0.06% (1/1787) and 1.0% (18/1787), respectively. Regression analysis indicated that women who did not receive syphilis or HIV testing before were less likely to accept dual RDT (OR 0.28, 95% CI 0.10 to 0.75). Acceptance for dual RDT testing at second or third antenatal visit was lower compared with the first visit (OR 0.37, 95% CI 0.15 to 0.94). CONCLUSION: Combined dual HIV/syphilis RDT with same-day results increased uptake of HIV and syphilis testing among pregnant women at primary healthcare facilities. Given the diversity of testing capacities among health services especially in rural areas in China, the dual RDT kit is feasible tool to improve testing uptake among pregnant women.

Medical treatments for incomplete miscarriage.

BACKGROUND: Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable. OBJECTIVES: To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers. SELECTION CRITERIA: We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS: The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.

Epidemic Profile of Maternal Syphilis in China in 2013.

OBJECTIVE: The aim of this study was to investigate the epidemiological characteristics and adverse pregnancy outcomes of pregnant women with syphilis infection in China. METHODS: Data were from China's Information System of Prevention of Mother-to-Child Transmission of Syphilis Management. Women who were registered in the system and delivered in 2013 were included in the analysis. RESULTS: A total of 15884 pregnant women with syphilis infection delivered in China in 2013. 79.1% of infected women attended antenatal care at or before 37 gestational weeks; however, 55.4% received no treatment or initiated the treatment after 37 gestational weeks. 14.0% of women suffered serious adverse pregnancy outcomes including stillbirth/neonatal death, preterm delivery/low birth weight, or congenital syphilis in newborns. High maternal titer (≥1 : 64) and late treatment (>37 gestational weeks)/nontreatment were significantly associated with increased risk of congenital syphilis and the adjusted ORs were 1.88 (95% CI 1.27 to 2.80) and 3.70 (95% CI 2.36 to 5.80), respectively. CONCLUSION: Syphilis affects a great number of pregnant women in China. Large proportions of women are not detected and treated at an early pregnancy stage. Burden of adverse pregnancy outcomes is high among infected women. Comprehensive interventions still need to be strengthened to improve uptake of screening and treatment for maternal syphilis.

Chinese herbal medicines for unexplained recurrent miscarriage.

BACKGROUND: Recurrent miscarriage affects 1% to 3% of women of reproductive age and mostly occurs before the 10th week of gestation (and around the same gestational week in subsequent miscarriages). Although most pregnant women may not recognise a miscarriage until uterine bleeding and cramping occur, a repeat miscarriage after one or more pregnancy loss and the chance of having a successful pregnancy varies. To date, there is no universally accepted treatment for unexplained recurrent miscarriage. Chinese herbal medicines have been widely used in Asian societies for millennia and have become a popular alternative to Western medicines in recent years. Many clinical studies have reported that Chinese herbal medicines can improve pregnancy outcomes for pregnant women who had previously suffered recurrent miscarriage. This systematic review evaluated the efficacy of Chinese herbal medicines for recurrent miscarriage. OBJECTIVES: To assess the effectiveness and safety of Chinese herbal medicines for the treatment of unexplained recurrent miscarriage. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (01 June 2015), Embase (1980 to 01 June 2015); Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 01 June 2015); Chinese Biomedical Database (CBM) (1978 to 01 June 2015); China Journal Net (CJN) (1915 to 01 June 2015); China Journals Full-text Database (1915 to 01 June 2015); and WanFang Database (Chinese Ministry of Science & Technology) (1980 to 01 June 2015). We also searched reference lists of relevant trials and reviews. We identified and contacted organisations, individual experts working in the field, and medicinal herb manufacturers. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials, including cluster-randomised trials, with or without full text, comparing Chinese herbal medicines (alone or combined with other intervention or other pharmaceuticals) with placebo, no treatment, other intervention (including bed rest and psychological support), or other pharmaceuticals as treatments for unexplained recurrent miscarriage. Cross-over studies were not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed all the studies for inclusion in the review, assessed risk of bias and extracted the data. Data were checked for accuracy. MAIN RESULTS: We included nine randomised clinical trials (involving 861 women). The trials compared Chinese herbal medicines (various formulations) either alone (one trial), or in combination with other pharmaceuticals (seven trials) versus other pharmaceuticals alone. One study compared Chinese herbal medicines and other pharmaceuticals versus psychotherapy. We did not identify any trials comparing Chinese herbal medicines with placebo or no treatment, including bed rest.Various Chinese herbal medicines were used in the different trials (and some of the classical the formulations were modified in the trials). The Western pharmaceutical medicines included tocolytic drugs such as salbutamol and magnesium sulphate; hormonal supplementation with human chorionic gonadotrophin (HCG), progesterone or dydrogesterone; and supportive supplements such as vitamin E, vitamin K and folic acid.Overall, the methodological quality of the included studies was poor with unclear risk of bias for nearly all the 'Risk of bias' domains assessed.Chinese herbal medicines alone versus other pharmaceuticals alone - the live birth rate was no different between the two groups (risk ratio (RR) 1.05; 95% confidence interval (CI) 0.67 to 1.65; one trial, 80 women). No data were available for the outcome of pregnancy rate (continuation of pregnancy after 20 weeks of gestation).In contrast, the continuing pregnancy rate (RR 1.27 95% CI 1.10 to 1.48, two trials, 189 women) and live birth rate (average RR 1.55; 95% CI 1.14 to 2.10; six trials, 601 women, Tau² = 0.10; I² = 73%) were higher among the group of women who received a combination of Chinese herbal medicines and other pharmaceuticals when compared with women who received other pharmaceuticals alone.For Chinese herbal medicines and psychotherapy versus psychotherapy alone (one study) - there was a higher live birth rate (RR 1.32; 95% CI 1.07 to 1.64; one trial, 90 women) in the group of women who received a combination of Chinese herbal medicines and psychotherapy compared to those women who received psychotherapy alone. No data were available on the continuing pregnancy rate for this comparison.Other primary outcomes (maternal adverse effect and toxicity rate and the perinatal adverse effect and toxicity rate) were not reported in most of the included studies. Two trials (341 women) reported that no maternal adverse effects were found (one trial compared (combined) medicines with other pharmaceuticals, and one trial compared combined Chinese herbal medicine alone versus other pharmaceuticals). One trial (Chinese herbal medicine alone versus other pharmaceuticals alone) reported that there were no abnormal fetuses (ultrasound) or after delivery.There were no data reported for any of this review's secondary outcomes. AUTHORS' CONCLUSIONS: We found limited evidence (from nine studies with small sample sizes and unclear risk of bias) to assess the effectiveness of Chinese herbal medicines for treating unexplained recurrent miscarriage; no data were available to assess the safety of the intervention for the mother or her baby. There were no data relating to any of this review's secondary outcomes. From the limited data we found, a combination of Chinese herbal medicines and other pharmaceuticals (mainly Western medicines) may be more effective than Western medicines alone in terms of the rate of continuing pregnancy and the rate of live births. However, the methodological quality of the included studies was generally poor.A comparison of Chinese herbal medicines alone versus placebo or no treatment (including bed rest) was not possible as no relevant trials were identified.More high-quality studies are needed to further evaluate the effectiveness and safety of Chinese herbal medicines for unexplained recurrent miscarriage. In addition to assessing the effect of Chinese herbal medicines on pregnancy rate and the rate of live births, future studies should also consider safety issues (adverse effects and toxicity for the mother and her baby) as well as the secondary outcomes listed in this review. This review would provide more valuable information if the included studies could overcome the problems in their designs, such as lacking of qualified placebo-controlled trials, applying adequate randomisation methods and avoiding potential bias.

Vitamin A supplementation during pregnancy for maternal and newborn outcomes.

BACKGROUND: The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection.   OBJECTIVES: To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies. SELECTION CRITERIA: All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: We reviewed 106 reports of 35 trials, published between 1931 and 2015. We included 19 trials including over 310,000 women, excluded 15 trials and one is ongoing. Overall, seven trials were judged to be of low risk of bias, three were high risk of bias and for nine it was unclear. 1) Vitamin A alone versus placebo or no treatmentOverall, when trial results are pooled, vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.65 to 1.20; four trials Ghana, Nepal, Bangladesh, UK, high quality evidence), perinatal mortality (RR 1.01, 95% CI 0.95 to 1.07; one study, high quality evidence), neonatal mortality, stillbirth, neonatal anaemia, preterm birth (RR 0.98, 95% CI 0.94 to 1.01, five studies, high quality evidence), or the risk of having a low birthweight baby.Vitamin A supplementation reduces the risk of maternal night blindness (RR 0.79, 95% CI 0.64 to 0.98; two trials). There is evidence that vitamin A supplements may reduce maternal clinical infection (RR 0.45, 95% CI 0.20 to 0.99, five trials; South Africa, Nepal, Indonesia, Tanzania, UK, low quality evidence) and maternal anaemia (RR 0.64, 95% CI 0.43 to 0.94; three studies, moderate quality evidence). 2) Vitamin A alone versus micronutrient supplements without vitamin AVitamin A alone compared to micronutrient supplements without vitamin A does not decrease maternal clinical infection (RR 0.99, 95% CI 0.83 to 1.18, two trials, 591 women). No other primary or secondary outcomes were reported 3) Vitamin A with other micronutrients versus micronutrient supplements without vitamin AVitamin A supplementation (with other micronutrients) does not decrease perinatal mortality (RR 0.51, 95% CI 0.10 to 2.69; one study, low quality evidence), maternal anaemia (RR 0.86, 95% CI 0.68 to 1.09; three studies, low quality evidence), maternal clinical infection (RR 0.95, 95% CI 0.80 to 1.13; I² = 45%, two studies, low quality evidence) or preterm birth (RR 0.39, 95% CI 0.08 to 1.93; one study, low quality evidence).In HIV-positive women vitamin A supplementation given with other micronutrients was associated with fewer low birthweight babies (< 2.5 kg) in the supplemented group in one study (RR 0.67, 95% CI 0.47 to 0.96; one study, 594 women). AUTHORS' CONCLUSIONS: The pooled results of three large trials in Nepal, Ghana and Bangladesh (with over 153,500 women) do not currently suggest a role for antenatal vitamin A supplementation to reduce maternal or perinatal mortality. However, the populations studied were probably different with regard to baseline vitamin A status and there were problems with follow-up of women. There is good evidence that antenatal vitamin A supplementation reduces maternal night blindness, maternal anaemia for women who live in areas where vitamin A deficiency is common or who are HIV-positive. In addition the available evidence suggests a reduction in maternal infection, but these data are not of a high quality.

Analysis of context factors in compulsory and incentive strategies for improving attraction and retention of health workers in rural and remote areas: a systematic review.

BACKGROUND: Current literature systematically reports that interventions to attract and retain health workers in underserved areas need to be context specific but rarely defines what that means. In this systematic review, we try to summarize and analyse context factors influencing the implementation of interventions to attract and retain rural health workers. METHODS: We searched online databases, relevant websites and reference lists of selected literature to identify studies on compulsory rural service programmes and financial incentives. Forty studies were selected. Information regarding context factors at macro, meso and micro levels was extracted and synthesized. RESULTS: Macro-level context factors include political, economic and social factors. Meso-level factors include health system factors such as maldistribution of health workers, growing private sector, decentralization and health financing. Micro-level factors refer to the policy implementation process including funding sources, administrative agency, legislation process, monitoring and evaluation. CONCLUSIONS: Macro-, meso- and micro-level context factors can play different roles in agenda setting, policy formulation and implementation of health interventions to attract and retain rural health workers. These factors should be systematically considered in the different stages of policy process and evaluation.

Health care utilization in older people with cardiovascular disease in China.

BACKGROUND: Population is ageing rapidly and prevalence of cardiovascular diseases is increasing in China. This study aims to examine the patterns of outpatient and inpatient health care utilization across different demographic and socioeconomic groups in older people with cardiovascular disease in China. METHODS: Data were from World Health Organization (WHO) Study on Global Aging and Adult Health (SAGE) Wave 1. Chinese older people aged over 50 years with cardiovascular disease were included in the analysis. Outpatient and inpatient care utilization rates were presented and compared by demographic and socioeconomic characteristics. Multivariable logistic regression was used to examine the association between socioeconomic factors and health care utilization. RESULTS: In total, 4162 older people with cardiovascular disease in SAGE China Wave 1 were included in the analysis. 86.4% of them had health insurance. 54.9% of the patients received outpatient care and 17.7% received inpatient care over the past 12 months. Outpatient care utilization rate was significantly associated with age. Patients in older groups used more outpatient care than those in younger groups (p = 0.010). Inpatient care utilization rate peaked at 70-79 years group (23.2%), and then reduced to 17.5% in 80 years plus group. Rich patients used more outpatient service than the poorer (p < 0.001). No association was found between household wealth status and inpatient service utilization. CONCLUSION: Within the context of high health insurance coverage in China, the pattern of outpatient care utilization differs from that of inpatient care utilization among older patients aged over 50 years old with cardiovascular disease. Patients tend to use more outpatient care as they became older. As for inpatient care, the oldest patients aged over 80 years use less inpatient care than the 70-79 group. Household economic status plays an important role in outpatient care utilization, but it shows no association with inpatient care utilization in Chinese older patients.

[Incidence of and related risk factors on preterm delivery among HIV-infected pregnant women in China].

OBJECTIVE: To measure the incidence rates of preterm delivery in HIV-infected pregnant women and to explore related potential risk factors. METHODS: Data from 'Information System of Prevention of Mother-to-child Transmission of HIV Management in China, 2013' was used in the study. Information regarding demographic characteristics, pregnancy, HIV relevant situations and pregnancy outcomes related to these HIV-infected pregnant women, were extracted and analyzed. Incidence of preterm delivery was calculated with related potential risk factors explored. RESULTS: 3 913 HIV-infected pregnant women were involved in this study, including 336 of them having undergone preterm deliveries (8.6%). Results from univariate and multivariate analyses showed that preterm delivery was associated with factors as: maternal age, ethnicity, education, being migrant, pregnancy hypertension, multiple pregnancy and times of antenatal care visits (P < 0.05) of the pregnant women. Compared with those who contracted the HIV infection through drug injection, the ones who were infected through other routes suffered fewer preterm deliveries (adjusted OR = 0.562, 95% CI: 0.360-0.879). Pregnant women who received antiretroviral therapy either between 14 to 27 gestational weeks or during the period of less than 14, were more likely to experience preterm delivery, comparison to those who did not receive the therapy during pregnancy. The adjusted ORs were 1.712 (95% CI: 1.196-2.451) and 1.862 (95% CI: 1.261-2.749), respectively. CONCLUSION: Preterm delivery was a common adverse outcome during pregnancy among HIV-infected women in China. Other than traditionally known risk factors, routes of transmission and the use of antiretroviral therapy might also be associated with the increased risks for preterm delivery.

Different classes of antibiotics given to women routinely for preventing infection at caesarean section.

BACKGROUND: Caesarean section increases the risk of postpartum infection for women and prophylactic antibiotics have been shown to reduce the incidence; however, there are adverse effects. It is important to identify the most effective class of antibiotics to use and those with the least adverse effects. OBJECTIVES: To determine, from the best available evidence, the balance of benefits and harms between different classes of antibiotic given prophylactically to women undergoing caesarean section. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014) and reference lists of retrieved papers. SELECTION CRITERIA: We included randomised controlled trials comparing different classes of prophylactic antibiotics given to women undergoing caesarean section. We excluded trials that compared drugs with placebo or drugs within a specific class; these are assessed in other Cochrane reviews. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. MAIN RESULTS: We included 35 studies of which 31 provided data on 7697 women. For the main comparison between cephalosporins versus penicillins, there were 30 studies of which 27 provided data on 7299 women. There was a lack of good quality data and important outcomes often included only small numbers of women.For the comparison of a single cephalosporin versus a single penicillin (Comparison 1 subgroup 1), we found no significant difference between these classes of antibiotics for our chosen most important seven outcomes namely: maternal sepsis - there were no women with sepsis in the two studies involving 346 women; maternal endometritis (risk ratio (RR) 1.11, 95% confidence interval (CI) 0.81 to 1.52, nine studies, 3130 women, random effects, moderate quality of the evidence); maternal wound infection (RR 0.83, 95% CI 0.38 to 1.81, nine studies, 1497 women, random effects, low quality of the evidence), maternal urinary tract infection (RR 1.48, 95% CI 0.89 to 2.48, seven studies, 1120 women, low quality of the evidence) and maternal composite adverse effects (RR 2.02, 95% CI 0.18 to 21.96, three studies, 1902 women, very low quality of the evidence). None of the included studies looked for infant sepsis nor infant oral thrush.This meant we could only conclude that the current evidence shows no overall difference between the different classes of antibiotics in terms of reducing maternal infections after caesarean sections. However, none of the studies reported on infections diagnosed after the initial postoperative hospital stay. We were unable to assess what impact, if any, the use of different classes of antibiotics might have on bacterial resistance. AUTHORS' CONCLUSIONS: Based on the best currently available evidence, cephalosporins and penicillins have similar efficacy at caesarean section when considering immediate postoperative infections. We have no data for outcomes on the baby, nor on late infections (up to 30 days) in the mother. Clinicians need to consider bacterial resistance and women's individual circumstances.

Medical treatments for incomplete miscarriage.

BACKGROUND: Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES: To assess the effectiveness, safety and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers. SELECTION CRITERIA: Randomised controlled trials comparing medical treatment with expectant care or surgery or alternative methods of medical treatment. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS: Twenty studies (4208 women) were included. There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no statistically significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women, random-effects), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women, random-effects). There were few data on 'deaths or serious complications'.Twelve studies involving 2894 women addressed the comparison of misoprostol (six studies used oral administration, four studies used vaginal, one study sub-lingual, one study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.97, 95% CI 0.95 to 0.99, 11 studies, 2493 women, random-effects) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.06, 95% CI 0.02 to 0.13; 11 studies, 2654 women, random-effects) but more unplanned procedures (average RR 5.82, 95% CI 2.93 to 11.56; nine studies, 2274 women, random-effects). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.41, 95% CI 1.44 to 4.03; nine studies, 2179 women, random-effects).Five trials compared different routes of administration and/or doses of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS: The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice. Future studies should include long-term follow-up.

Chinese herbal medicines for threatened miscarriage.

BACKGROUND: Threatened miscarriage occurs in 10% to 15% of all pregnancies. Vaginal spotting or bleeding during early gestation is common, with nearly half of those pregnancies resulting in pregnancy loss. To date, there is no effective preventive treatment for threatened miscarriage. Chinese herbal medicines have been widely used in Asian countries for centuries and have become a popular alternative to Western medicines in recent years. Many studies claim to show that they can prevent miscarriage. However, there has been no systematic evaluation of the effectiveness of Chinese herbal medicines for threatened miscarriage. OBJECTIVES: To review the therapeutic effects of Chinese herbal medicines for the treatment of threatened miscarriage. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2012), Chinese Biomedical Database (1978 to 31 January 2012), China Journal Net (1915 to 31 January 2012), China National Knowledge Infrastructure (1915 to 31 January 2012), WanFang Database (1980 to 31 January 2012), Chinese Clinical Trial Registry (31 January 2012), EMBASE (1980 to 31 January 2012), CINAHL (31 January 2012), PubMed (1980 to 31 January 2012), Wiley InterScience (1966 to 31 January 2012), International Clinical Trials Registry Platform (31 January 2012) and reference lists of retrieved studies. We also contacted organisations, individual experts working in the field, and medicinal herb manufacturers. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials that compared Chinese herbal medicines (alone or combined with other pharmaceuticals) with placebo, no treatment (including bed rest), or other pharmaceuticals as treatments for threatened miscarriage. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed all the studies for inclusion in the review, assessed risk of bias and extracted the data. Data were checked for accuracy. MAIN RESULTS: In total, we included 44 randomised clinical trials with 5100 participants in the review.We did not identify any trials which used placebo or no treatment (including bed rest) as a control.The rate of effectiveness (continuation of pregnancy after 28 weeks of gestation) was not significantly different between the Chinese herbal medicines alone group compared with the group of women receiving Western medicines alone (average risk ratio (RR) 1.23; 95% confidence interval (CI) 0.96 to 1.57; one trial, 60 women).Chinese herbal medicines combined with Western medicines were more effective than Western medicines alone to continue the pregnancy beyond 28 weeks of gestation (average RR 1.28; 95% CI 1.18 to 1.38; five trials, 550 women). AUTHORS' CONCLUSIONS: There was insufficient evidence to assess the effectiveness of Chinese herbal medicines alone for treating threatened miscarriage.A combination of Chinese herbal and Western medicines was more effective than Western medicines alone for treating threatened miscarriage. However, the quality of the included studies was poor. More high quality studies are necessary to further evaluate the effectiveness of Chinese herbal medicines for threatened miscarriage.

Vitamin A supplementation during pregnancy for maternal and newborn outcomes.

BACKGROUND: The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection.   OBJECTIVES: To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 July 2010). SELECTION CRITERIA: All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed all studies for inclusion and resolved any disagreement through discussion with a third person. We used pre-prepared data extraction sheets. MAIN RESULTS: We examined 88 reports of 31 trials, published between 1931 and 2010, for inclusion in this review. We included 16 trials, excluded 14, and one is awaiting assessment.Overall when trial results are pooled, Vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.55 to 1.10, 3 studies, Nepal, Ghana,UK ), perinatal mortality, neonatal mortality, stillbirth, neonatal anaemia, preterm birth or the risk of having a low birthweight baby. Vitamin A supplementation reduces the risk of maternal night blindness (risk ratio (RR) 0.70, 95% CI 0.60 to 0.82, 1 trial Nepal). In vitamin A deficient populations and HIV-positive women, vitamin A supplementation reduces maternal anaemia (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.43 to 0.94, 3 trials, Indonesia, Nepal,Tanzania ). There is evidence that vitamin A supplements may reduce maternal clinical infection (RR 0.37, 95% CI 0.18 to 0.77, 3 trials, South Africa, Nepal and UK).In HIV-positive women vitamin A supplementation given with other micronutrients was associated with fewer low birthweight babies (< 2.5 kg) in the supplemented group in one study (RR 0.67, CI 0.47 to 0.96). AUTHORS' CONCLUSIONS: The pooled results of two large trials in Nepal and Ghana (with almost 95,000 women) do not currently suggest a role for antenatal vitamin A supplementation to reduce maternal or perinatal mortality. However the populations studied were probably different with regard to baseline vitamin A status and there were problems with follow-up of women. There is good evidence that antenatal vitamin A supplementation reduces maternal anaemia for women who live in areas where vitamin A deficiency is common or who are HIV-positive. In addition the available evidence suggests a reduction in maternal infection, but these data are not of a high quality.

Different classes of antibiotics given to women routinely for preventing infection at caesarean section.

BACKGROUND: Caesarean section increases the risk of postpartum infection for women and prophylactic antibiotics have been shown to reduce the incidence; however, there are adverse effects. It is important to identify the most effective class of antibiotics to use and those with the least adverse effects. OBJECTIVES: To determine, from the best available evidence, the balance of benefits and harms between different classes of antibiotic given prophylactically to women undergoing caesarean section. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2010) and reference lists of retrieved papers. SELECTION CRITERIA: We included randomised controlled trials comparing different classes of prophylactic antibiotics given to women undergoing caesarean section. We excluded trials that compared drugs with placebo or drugs within a specific class; these are assessed in other Cochrane Reviews. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. MAIN RESULTS: We included 29 studies of which 25 provided data on 6367 women. There was a lack of good quality data and important outcomes often included only small numbers of women. This meant we could only conclude that the current evidence shows no overall difference between the different classes of antibiotics in terms of reducing maternal infections after caesarean sections. However, none of the studies looked at outcomes on the baby, nor did they report infections diagnosed after the initial postoperative hospital stay. We were unable to assess what impact, if any, the use of different classes of antibiotics might have on bacterial resistance. AUTHORS' CONCLUSIONS: Based on the best currently available evidence, cephalosporins and penicillins have similar efficacy at caesarean section when considering immediate postoperative infections. We have no data for outcomes on the baby, nor on late infections (up to 30 days) in the mother. Clinicians need to consider bacterial resistance and women's individual circumstances.

Medical treatments for incomplete miscarriage (less than 24 weeks).

BACKGROUND: Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining pregnancy tissues in the uterus. However, it has been suggested that drug-based medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES: To assess the effectiveness, safety and acceptability of any medical treatment for early incomplete miscarriage (before 24 weeks). SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009). SELECTION CRITERIA: Randomised controlled trials comparing medical treatment with expectant care or surgery. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS: Fifteen studies (2750 women) were included, there were no studies on women over 13 weeks' gestation. Studies addressed a number of comparisons and data are therefore limited.Three trials compared misoprostol treatment (all vaginally administered) with expectant care. There was no significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women). There were few data on 'deaths or serious complications'.Nine studies involving 1766 women addressed the comparison of misoprostol (four oral, four vaginal, one vaginal + oral) with surgical evacuation. There was no statistically significant difference in complete miscarriage (average RR 0.96, 95% CI 0.92 to 1.00, eight studies, 1377 women) with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.07, 95% CI 0.03 to 0.18; eight studies, 1538 women) but more unplanned procedures (average RR 6.32, 95% CI 2.90 to 13.77; six studies, 1158 women). There were few data on 'deaths or serious complications'. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS: The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice.

A study of dilational rheological properties of polymers at interfaces.

Viscoelastic properties of two polymers, partially hydrolyzed polyacrylamide and partially hydrolyzed modified polyacrylamide, widely used in chemical flooding in the petroleum industry, were investigated at three interfaces, water-air, water-dodecane, and water-crude oil, by means of a dilational method provided by I.T. Concept, France, at 85 degrees C. Polymer solutions were prepared in brine with 10,000 mg/l sodium chloride and 2000 mg/l calcium chloride. It has been shown that the viscoelastic modulus increases with the increment of polymer concentration in the range of 0-1500 mg/l at the water-air interface. Each polymer shows different viscoelatic behavior at different interfaces. Generally speaking, values of the viscoelastic modulus (E), the real part (E'), and the imaginary part (E") at the crude oil-water interface for each polymer are lower than at the air-water or water-dodecane interface. The two polymers display different interfacial properties at the same interface. Polymer No. 2 gives more viscous interfaces than polymer No. 1. All the information obtained from this paper will be helpful in understanding the interfacial rheology of ultra-high-molecular-weight polymer solutions.